Anorexia Nervosa is a complex disorder. The diagnostic criteria as defined by the DSM-V is the “restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health; intense fear of gaining weight or becoming fat, even though underweight; disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight” (American Psychological Association, 2013, pp.338-339). The incidence of diagnosed eating disorders is estimated to be 4.95% for women, and research indicates that one in eight women in the United States are impacted by subclinical disordered eating (Beccia, Dunlap, Hanes, Courneene & Zwickey, 2017). Barriers to recovery include “poor outcomes for most therapeutic approaches, high rates of chronicity and relapse, and high rates of treatment dropout among patients” (Beccia et al., 2017, p. 1). Relapse rates are between 22-60% (Troyer, 2014) and the difficulty in treating this disorder is apparent as research has indicated that “twelve years post-treatment, approximately 27% of patients with AN still qualify for eating disorder diagnosis… 10 years post-treatment, only 10% to 11% of AN patients were completely symptom-free” (Scott et al., 2013, p. 308). It has also been indicated that individuals with anorexia are 32 times more likely to die by suicide than the general population (Weber et al., 2006).
Each individual’s lived experience of anorexia is different; however it has been indicated that “less bodily-focused anorexia is a state of mind, a means of keeping in control” (Lock et al., 2005, p.329). It has also been referred to as “a disorder of embodiment, a disembodiment, that implies a disconnection with own body” (Zatti & Zarbo, 2015, p. 2). Anorexia can be seen as a psycho-somatic disorder whereby the individual attempts to separate her mind from her body. This creates a mind-body dichotomy in which the “mind is seen as the true self and the body is merely its containment” (Sharpe, 2011, p. 9). Individuals with anorexia “lack an accurate and stable internal image of their bodies” (Sands, 2016, p. 29). They experience a separation from their bodies and this disembodiment causes them to treat their body as if it were an object rather than the means through which they are able to experience this world.
There is no perfect construct to depict what is meant and experienced when referring to body image, but re-framing it as embodiment is more encompassing and inclusive of the somatic nature of the body.
Typical treatment of anorexia includes cognitive behavioral therapy whereby it is believed that external variables can be controlled by cognitions and behavior. This implies that “women with eating disorders can simply think their way back into a healthy relationship with their bodies by restricting the cultural messages that play a large part in the creation and maintenance of disordered eating” (Sharpe, 2011, p. 11). Such treatment modalities are limiting and invalidate the individuals’ lived experience as it is not as simple as thinking oneself into recovery from such a complex disorder. In addition, treatment centers tend to focus primarily on food/body/weight restoration, which makes sense given the urgency to tend to malnutrition, however, this approach encourages more of the same dualistic thinking whereby the “body is treated as a machine that requires medical and psychological intervention to function properly” (Sharpe, 2011, p. 10). The current psycho-medical constructs of anorexia understand it as being an “internalized, psycho-medical feminine phenomenon; that is, a person is anorexic, has anorexia, suffers from anorexia” (Botha, 2015, p. 330), pathologizing the person and simplifying this lived experience to one’s cognitions.
Language of body image and embodiment
“The terms that are used in the dominant discourse surrounding eating disorders can be viewed as thin descriptions. Body dissatisfaction, negative body image, body image disturbance, body distortion, and low body/self-esteem are terms that pathologize and classify people as dysfunctional” (Sharpe, 2011, p. 13). Such language is limiting and based on the dualistic framework whereby the individual herself is the source of the problem. “An individual’s actual body-image is often the distorted representation of a real and undistorted body concept that an individual should have, on the basis of how s/he ‘really’ is” (Waskul & Vannini, 2006, p. 2). This definition of body image implies that it is an objective construct which exists outside of the individual, when in reality nothing is purely objective; each individual’s truth is different and exists within their being; bodies are intelligent (Brandt, 2006). There is no perfect construct to depict what is meant and experienced when referring to body image, but re-framing it as embodiment is more encompassing and inclusive of the somatic nature of the body. This somatization acknowledges the fact that the body gives us the experience of “sensing and being in the world” (Waskul & Vannini, 2006, p.15).
Embodiment is a construct through which we can create a connection and dissolve the boundaries found within notions of the mind-body dichotomy. With the mind-body split, the “mind is valued over the body” (Brandt, 2006), which creates a sense of otherness between the two entities which is a paradox as they are immanent. Embodiment is inclusive of sensation; a vital component of our existence as for “meanings to be had, they must be sensed” (Brant, 2006). Sensation occurs at the level of embodiment whereby sensing/perceiving precedes interpretation and making sense of whatever it is we are experiencing. Embracing the language of embodiment requires us to recognize our bodies as the “wellspring of existence and the site of experience” (Csordas, 20111, p. 137). It is a construct which can help us decipher our “existential condition” (Csordas, 2011) from a different lens rather than continuing to use the thin descriptions historically used to describe body image and honors the body as our “mode of being in the world” (Brandt, 2006).
Mindfulness and embodiment
Mindfulness is a skill “that allows us to be less reactive to what is happening in the moment. It is a way of relating to all experience—positive, negative and neutral—such that our overall suffering is reduced and our sense of well-being increases” (Germer, 2004, p. 24). For an individual with an eating disorder, this skill can improve their sense of connection with their body as they learn how to be in the moment and feel through their emotions, responding to them with self-compassion, instead of reacting through the engagement of unhealthy coping mechanisms.
Acceptance is another component that can be integrated through the use of equine-assisted therapy as it relates to mindfulness. It is a non-judgmental stance that can help an individual be in the moment and accept it as it is. For clients with eating disorders, this is a vital piece as they have to learn to make peace with their body as well as whatever contextual experiences arise that they find triggering, be it relational or environmental. Equine-assisted therapy can help an individual integrate the concepts of mindfulness and acceptance into their life as “horses facilitate awareness of our own instinctual nature and its influence on our thoughts, behaviors and feelings” (Halberg, 2008, p.15).
Using horses to access the gift of mindfulness makes sense, as they, too, are reactive beings. Horses express their emotional pain through physical means. Examples include, “head shaking, body weaving, pacing, wood chewing, and cribbing, or sucking in air. These are all coping behaviors horses engage in to reduce their anxiety and stress. And just as with addictive behaviors in humans, some of these habitual neurotic patterns can stimulate the horse’s brain to release endorphins, the same chemical that provides us emotional soothing. This is identical to the way some humans ‘self-medicate’ their emotional stress and anxiety with compulsive behaviors like exercise, work, sex, or eating, any of which also serve to alter their brain chemistry” (Hayes, 2015, p.28). Therefore, horses can be valuable teachers to those with eating disorders as they can help clients learn how to stay in the moment, connect with their emotions while at the same time treating their body through a lens of nurturance and love rather than escaping when they feel triggered.
Equine therapy helps develop mindfulness in clients as “horses are masters of being in the moment” (Green et al, 2018, p.163). Mindfulness brings us into the here and now, so that we are truly able to show up and be in the moment. There is a disconnect between the body and the mind when one engages in unhealthy behaviors. This is often seen among individuals with eating disorders as they attempt to escape the pain they are feeling through engaging in unhealthy behaviors typically revolving around food and exercise. These behaviors provide them with a means of temporary relief from their experience, but the consequences of such behaviors have numerous repercussions on both a physical as well as a psychological level. The exercises used in equine therapy provide rich experiences for the client to heal as “sessions provide excellent metaphors for the eating disorder, specific people, and experiences in the patient’s life, and the recovery process” (Christian, 2005, p.65).
The mind-body dichotomy that one experiences with an eating disorder can be helped by integrating mindfulness as one connects with one’s inner experience. “Eating disorders can be seen as a somatic disorder related to body alienation and the desensitization of emotions and physical sensations in the body” (Lac et al, 2013, p. 488). Connecting with the horse allows one to “step into the core of our being, connect with our strength within, and expand into the present moment of our world” (Willerson & Sanford, 2018, p.184).
Healing through the horse-human relationship
Horses are models of embodiment and congruence. They present themselves as they are feeling in the moment. The horse is able to exist in an embodied state whereby their sensitivity to the surrounding energy is communicated with the client. They have the potential to be valuable models for those clients with eating disorders as they can help clients present as themselves and connect to their true selves. Horses are always in the moment and this brilliant state of being reflects a connection between the body and the mind. They embody the notion that the “body is of the mind as the mind is of the body” (Waskul & Vannini, 2006, p. 19).
It has been noted that “if humans have smarter brains, horses have smarter bodies” (Smiley, 2004, p. 198). Since individuals with eating disorders are in a state of disembodiment, bodily knowledge is something which needs to be cultivated. Horses have the ability to show the individual this through mirroring. The power of mirroring has so much to offer an individual with an eating disorder as it makes one more aware of what they are truly feeling in that moment. The energy that they are projecting is sensed by the horse and it is through this connection that one is able to gain acceptance for their unique experience. Equine therapy has an edge over typical talk therapy for this very reason; clients are able to reflect on what it is they need through their interactions with the horses. No words are exchanged, only energy is felt, but this energy is very powerful and has the potential to help individuals become unstuck in whatever position they find themselves when they are in the moment and being mindful of the horse’s presence. The silent connection one builds with a horse can be stronger than a vocal human-human connection as it is based on a felt experience.
The healing process revolves around becoming more integrated with your true being. The horse can be used to help facilitate this process, thereby bringing one closer to understanding themselves. This understanding can be facilitated by a therapist, however adding the horse into the equation gives therapy a new angle on which one can reflect on their thoughts and behaviors as projected onto the horse. It’s fascinating that horses have this ability to act as a mirror; it invites the individual to re-evaluate their relationships, including the one they have with themselves. The horse’s response can provide the client with objective feedback on their behavior. Horses “tend to reflect the emotional state of the human. It’s like instant biofeedback” (Trotter, 2011, p. 24). The feedback one receives from the horse is in real time and there essentially is no filter; it just is what it is. This shines light on how their behavior is perceived/interpreted by other individuals which speaks to the relational component of equine therapy.
Equine therapy and embodiment
Sharpe (2014) conducted a research study on articulating bodily experience through the use of equine therapy for women with eating disorders. “Through dialogic movement and communication with their horses, the participants were able to attune in different ways to themselves and their worlds, thus interpreting some of the habitual practices of disordered eating” (Sharpe, 2014, p. 127). Attunement is similar to the concept of embodiment. Both relate to the internal experience one has within their reality; however, attunement expands upon embodiment as it includes how one engages and responds to this world; its relationships.
For an individual with an eating disorder different types of attunement manifest. Some may have an obsession with bodily control, some might repress their bodily experience by holding their body in a certain manner or smiling when uncomfortable, which “stems from the desire to be in control and disconnect from one’s own thoughts or feelings” (Sharpe, 2014). Using equine therapy improved the level of mindfulness among the women in Sharpe’s study as it helped them create new ways of attuning, which translated into new ways of being. They were able to connect to their emotions which helped them shift their attunement and allowed them to be open to having new bodily experiences. The women “learned to speak in a novel relational language in their interaction with their horses, as they attuned to each other through their bodies in a kinetically articulated way” (Sharpe, 2014, p. 142). The women had incredible experiences, which were made possible through their relationship with the horse. Working with the horses made it possible for them to connect with their core and thus experience an embodied state whereby they were able to attune to their reality in a new, healthier way.
Jen Cahill, MBA, MS, is an AAMFT Professional member currently awaiting degree conferral for her PhD. She studied couples and family therapy at Nova Southeastern University and her love for horses inspired her to explore how equine therapy can be integrated into systemic therapies.
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